A Remote Management-Centric Postdischarge Pathway for Patients Admitted to GIM with Heart Failure - 18/01/25

Doi : 10.1016/j.amjmed.2024.12.017

William K. Silverstein, MD, MSc ^a,^b,^c,^d,^⁎ , Sarah Lawrason, MSc, PhD ^e,^f, Iris Carabuena, RN ^g, Rodrigo B. Cavalcanti, MD, MSc ^a,^d,^h, Stella Kozuszko, RN-EC ^g, Thomas E. MacMillan, MD, MSc ^a,^d,^h, Shail Rawal, MD, MPH ^a,^d,^h, Lara Wyss, RN ⁱ, Anne Simard, MHSc ^e,^g, Heather J. Ross, MD, MHSc ^a,^e,^g, Tarek Abdelhalim, MD ^a,^d,^h
^a Department of Medicine, University of Toronto, Toronto, Ontario, Canada
^b Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
^c Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
^d HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
^e Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
^f Public Health Agency of Canada, Ottawa, Ontario, Canada
^g Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
^h Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
ⁱ Integrated Comprehensive Care Program, University Health Network, Toronto, Ontario, Canada

^⁎Requests for reprints should be addressed to William Silverstein, MD, MSc, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Assistant Professor, Department of Medicine, University of TorontoDivision of General Internal Medicine, Sunnybrook Health Sciences Centre, Assistant Professor, Department of MedicineUniversity of Toronto

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 18 January 2025

Abstract

Background

Few GIM-specific heart failure transition of care (TOC) programs exist. We thus piloted a TOC program for heart failure patients discharged from GIM that incorporates a remote patient management program, Medly.

Methods

This single-centre, prospective proof-of-concept study described sociodemographic and medical characteristics of included patients, and computed summary statistics to describe clinical and workload outcomes.

Results

Ten patients (median age: 85) enrolled. There were no heart failure-related deaths, re-hospitalizations, or ED visits within 90 days of hospital discharge. One urgent GIM clinic visit was needed.

Conclusion

This post-GIM TOC pathway appears to effectively support heart failure patients. Further studies should assess this innovation's scalability.

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Keywords : Heart Failure, Hospital Medicine, Remote Patient Management, Transitions of Care

Plan

Introduction

Problem Description and Available Knowledge

Ethical Considerations

	Funding: This work is supported by the University Health Network's HoPingKong Centre for Excellence in Education and Practice Clinician Scholar Fellowship.
	Conflicts of Interest: Dr. Heather Ross holds intellectual property rights of the Medly system. No other conflicts of interest were declared. Dr. William Silverstein, Dr. Sarah Lawrason, Ms. Iris Carabuena. Dr. Rodrigo Cavalcanti, Ms. Stella Kozuszko, Dr. Thomas MacMillan, Dr. Shail Rawal, Ms. Lara Wyss, Ms. Anne Simard, and Dr. Tarek Abdelhalim have no conflicts of interest to declare.
	Authorship: All authors had access to data and a role in writing the manuscript. WKS: Writing – review & editing, Writing – original draft, Project administration, Funding acquisition, Formal analysis, Data curation, Conceptualization; SL: Writing – review & editing, Methodology, Formal analysis, Data curation; IC: Writing – review & editing, Data curation; RBC: Writing – review & editing, Supervision; SK: Writing – review & editing, Methodology; TEM: Writing – review & editing, Supervision; SR: Writing – review & editing, Supervision, Conceptualization; LW: Writing – review & editing, Methodology, Data curation; AS: Writing – review & editing, Supervision, Methodology; HJR: Writing – review & editing, Supervision, Resources, Conceptualization; TA: Writing – review & editing, Supervision, Conceptualization.